Older people with cancer: treatment planning

Physiological changes that occur with ageing, as well as multiple co-morbidities, can complicate management of cancers in older persons. For example, older people treated for cancer have increased susceptibility to therapeutic complications, such as severe and prolonged myelosuppression and mucositis, and increased risk of cardiomyopathy and central and peripheral neuropathy.28

Cancer treatment tolerance and outcomes are impacted upon by co morbidities, medication usage and by geriatric syndromes including frailty, functional impairment and cognitive impairments. Therefore, cancer treatment decision making is potentially more complex for older people as all these facets need to be incorporated into decisions.29 Individual treatment planning is imperative, given reports that the elderly are less likely to receive less intensive therapy, leading to poorer outcomes.30 Older people with cancer are underrepresented in clinical trials for new cancer therapies. Evidence about the efficacy and side effects of treatments in older people may be lacking, with older people less likely to be included in clinical trials, in part because most trial protocols require full treatment doses, which may not be appropriate for some older patients.28, 31-33

It has been suggested that the older person’s comorbidities and personal choice alone are unlikely to explain why the older person receives less intensive treatment.30

Healthcare professionals may make assumptions about an older person’s preferences about treatment and a decision that an older person will not be able to cope with treatment can be made without fully assessing their overall physical health.34

Healthcare professionals may feel less confident about how to manage treatment in older people.31, 35

Gaps in appropriate community support for older cancer patients may mean that healthcare professionals are less willing to offer intensive treatment.31, 35

Health professionals may assume an ability to represent the older person’s best interests without endorsement from them. The older people’s rights may be infringed and wishes neglected and they may not be managed in an ethical way due to beneficent ageism.36

Geriatric Assessment

The International Society of Geriatric Oncology (SIOG) recommends that the following domains are evaluated when determining treatment approaches:37

Functional status

Comorbidity

Cognition

Mental health status

Fatigue

Social status and support

Nutrition

Presence of geriatric syndromes.

The ideal approach to assessment of older people is a multidisciplinary geriatric assessment. A comprehensive geriatric assessment is a process that ‘determines an elderly person’s medical, psychosocial, functional, and environmental resources and problems’ with the aim of developing an individualised plan for treatment and follow-up, targeting identified impairments.38

A comprehensive geriatric assessment is time and resource intensive. Therefore SIOG recommend a two set approach, with initial screening for age related problems, enabling targeting of more in-depth assessment to older people most likely to benefit. No specific screening tool has been demonstrated to outperform other tools. If risk factors have been identified, a number of specific aged care assessment tools are available to supplement the assessment to identify the level of risk and subsequent intervention required.37

Key resource

An overview of screening and assessment of older people and tools and resources to support practice:Assessment. Victorian Government Health Information, 2014